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Appendix C Operational Systems Engineering Applications Based on Issues Raised by TBI Stakeholders A. Developing New Traumatic Brain Injury Knowledge Issue A.1. Develop an approach to modeling the neuropathology and clinical effects of blast and concussive injuries on brain func- tions leading to mild, moderate, or severe TBI. Purpose. Little is known about the phenomenology leading to TBI, particularly mild TBI (mTBI). This limits the objective diagnosis of TBI, effective management at the point of injury, and appropriate acute care. An understanding of the phenomenology would provide a basis for the development of effective treatment protocols. Output. (1) A description of TBI phenomenology (e.g., are there useful “brain vital signs”). (2) An objective means of estimating the probability distribution of the severity of TBI as a function of blast and concussive effects on the brain that can be related to the origin of the blast. Issue A.2. Develop an acute-to-chronic disease model of mTBI showing the evolution of disease states (symptoms?) over time for a population of mTBI patients, including both persons ­ exposed to blast who are asymptomatic and persons who are overtly s ­ ymptomatic. 141

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142 Systems Engineering to Improve Traumatic Brain Injury CARE Purpose. Little is known about the progression or disappearance of mTBI (related to blast injury) over long periods of time. This limits the effectiveness of triage, rehabilitation regimes, long-term chronic management of mTBI disease, and the best use of community ser- vices for mTBI patients. Output. (1) An objective means of evaluating the efficacy of differ- ent intervention protocols for the near- and long-term care of mTBI p ­ atients. (2) A means of assessing the value of “early ­interventions.” B. Detection and Screening of mTBI Conditions Issue B.1. Develop a model for the medical diagnosis/detection of mTBI based on current clinical experience of the events and processes leading to the onset and progression of the disease and on the questionnaires/testing of military personnel (e.g., Bayesian networks, influence networks). Purpose. Not much objective knowledge is available about the onset and progression of mTBI that can assist in the detection and screen- ing of mTBI patients. However, there is a lot of subjective infor- mation (e.g., experience in the medical community; neurological, cognitive and psychological testing; imaging; questionnaires) and mTBI incidence data that can be integrated as an interim diagnostic vehicle to assist in assessment, detection, and screening programs and in “return to duty” decisions. Output. A means of estimating the probability that an individual soldier returning from the field has mTBI. Issue B.2. Assuming the availability of a subjective mTBI ­diagnostic/ detection methodology or another means of estimating mTBI detec­ tion probabilities, develop the structure and processes of a quality control program for screening the population of in-field and return- ing soldiers for mTBI. Purpose. There is a need for better testing methods (cognitive, brain scans, other) that can be used (in combination with other information) to develop an effective, efficient screening process that

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appendix C 143 a ­ ppropriately considers Type I (sensitivity) and Type II (specificity) errors of the detection decision. In other words, we must improve the detection and identification of weak signals in the presence of substantial penalties of both false alarms (removing healthy soldiers from service) and misses (sending impaired soldiers back into harm’s way). The signals may not be evident as physical symptoms. Output. (1) A screening process and procedures for detecting mTBI in the population of soldiers returning from field operations. (2) An experience-based mTBI diagnostic/detection methodology and screening process as a means of assessing the utility of new testing methods (cognitive, brain scans, other). C. TBI Care Coordination and Communication Issue C.1. Develop the structure of a TBI information system to track, monitor, and cue care delivery for all TBI patients, no matter the severity of their injuries. The system should be useful for clinical monitoring and follow-up. In addition, it should be accessible to and cue all patients, patients’ families, and other relevant providers in the MHS, VA, and civilian sector. Purpose. DOD does not have a system-wide approach for tracking and monitoring TBI patients for effective management of their complete care. The coordination of care is poor between the MHS and VA systems, as well as among facilities and care providers at different levels and different medical facilities. Output. A proactive information system that will facilitate the tracking, monitoring, cueing, coordination, communication, and scheduling of care for TBI patients from “cradle to cure,” so that information flows and flows of care can be aligned to provide the most effective and timely status awareness and response capability for TBI patients. Issue C.2. Develop a methodology for coordinating the delivery of services for TBI and related co-morbidities immediately following trauma exposure. The methodology should take into account the needs and preferences of patients and family members, as well as the

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144 Systems Engineering to Improve Traumatic Brain Injury CARE resources (number and type of providers available, workload, etc.) and infrastructure of the relevant health care system. Purpose. This methodology would improve the timeliness, coordina- tion, and efficiency with which TBI care resources (care providers, equipment, material, supporting organizations, infrastructure) are brought to bear on the needs of TBI patients during the first two to three days after a critical event (initial injury or recognition of symptoms by caregivers or family members). The TBI care system must become more operationally responsive and better coordinated to improve both patient outcomes and to make efficient use of scarce resources. Output: An operational model and/or a process methodology that can be used for the real-time allocation of TBI care resources in order to provide coordinated and responsive delivery of clinical services. D. The Demand for TBI Care Issue D.1. Based on historical data on known mTBI detections/­ patients and improvised explosive device (IED) incidents, develop a statistical estimate of mTBI in the population of military personnel who have participated in the Iraq and Afghanistan wars. The esti- mate should include the “shadow” population of mTBI patients. Issue D.2. Develop a methodology to forecast the time stream of future TBI patients based on a projection of IED and other wartime blast phenomena in current and projected theaters of war. Specifi- cally, based on historical and test data on various types of IEDs, develop a model to estimate the severity of concussive blast effects on individuals as a function of the input characteristics, such as blast sizes and types, proximity of blast to individuals, physical shielding and protections available, duration and number of blasts and/or incidents. The estimates of blast concussive effects should then be used, in conjunction with the results of Issues A.1 and/or B.1, to estimate the future demand for care of TBI patients. Purpose. The effective management of resources available for TBI health care (providers, facilities, equipment, etc.) requires an

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appendix C 145 u ­ nderstanding of the current and projected demand for care of TBI and mTBI patients. Output. Estimates of current demand for TBI care and a methodol- ogy for estimating future demand for care of TBI and mTBI. Issue D.3. Develop elements of, and a process for, assessing the “value” of TBI preventive methods (e.g., education, outreach, pro- tective clothing and equipment, etc.) to DOD/VA, to potential TBI patients, and to their families/communities. Purpose. The military should improve its efforts to prevent TBI. Output. A means of assessing the value of alternative protection initiatives and a way to compare the costs and benefits of prevention and treatment. E. TBI Care System Capacity, Organization, and Resource Allocation Issue E.1. Develop a description of the elements, processes, and activities that represent the dynamics of a complete episode of TBI care at all levels of severity to include demand for TBI care, care processes (protocols), and care resources (providers, facilities, equipment). This description should be used for one of the purposes listed below: 1.  design an approach to develop a stand-alone model of the To TBI care system. OR 2.  design an approach to improve an existing enterprise-level To health care delivery model, including TBI system elements, care processes, resources, etc. Purpose. TBI-related capacity issues (requirements for providers, facilities, equipment, etc.), organizational issues (assessment of the cost-effectiveness of the TBI care system, evaluation of changes to it, impact of multiple and different TBI medical systems), and associated resource allocations must be assessed. The TBI system

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146 Systems Engineering to Improve Traumatic Brain Injury CARE of care involves many tactical-level and strategic-level interactions among elements, processes, activities, and organizations. In addi- tion, there are significant co-morbidities between TBI and mental health conditions, as well as between TBI and physical injuries, diseases, and conditions. Therefore, these analyses should also con- sider endogenous interactions and relevant co-morbidities from a “systems/enterprise” perspective. Output. A “TBI system” model or “enterprise level” health care d ­ elivery model that can address a broad spectrum of TBI capacity, organizational, and resource-allocation issues. If properly struc- tured, the model(s) could be used to design prospectively a TBI system of care. Issue E.2. Outline the structure of a (mathematical programming?) model/robust methodology to assist in planning for the allocation of scarce TBI care providers to meet the demand for care in theater and in the continental United States (CONUS) for all severity levels of TBI. (As an alternative, consider assigning TBI patients to specific care providers.) Purpose. There is a shortage of care providers with expertise in TBI care. In addition, specialty providers may now have responsibilities for the treatment of other diseases and/or may not be geographically distributed to provide efficient care to the existing and projected population of TBI patients. Although it may be less than optimal from a systems perspective, the military needs a method to assist in determining the best use of these scarce resources in the near term. Output. A methodology for allocating scarce TBI-capable care pro- viders to meet the demand for care for in-theater and in-CONUS populations of TBI patients. The methodology will also help iden- tify high-priority requirements for additional TBI care providers.